7.1 Local therapy
With respect to the skin barrier dysfunction as a pathognomonic factor
in the pathogenesis of AE, emollient therapy marks an essential element
in the disease management: Application of emollients in adequate amount
(>250g/week) and frequency (at least once, better twice a
day; additionally, after any skin cleansing) is necessary to enhance the
integrity of epidermal barrier and consequently reduce the
susceptibility for irritation and inflammation of the skin.
Interestingly, a pilot study has recently shown greater efficacy of a
novel trilipid cream (a 3:1:1 ratio of ceramides, cholesterol, and free
fatty acids) than a regular paraffin-based emollient considering the
reduction of transepidermal water loss [115].
Topical anti-inflammatory treatment is still the mainstay of
mild-to-moderate forms of AE and especially acute exacerbations due to a
reduction of pruritus and inflammation and restoration of skin barrier
function. Both topical corticosteroids (TCS) and calcineurin inhibitors
(TCI) have shown to be safe and effective for reducing acute flares and
risk of relapse if applied in an appropriate intensity and dosage,
especially in a proactive setting (e.g. twice weekly usage on
predilection areas). Concomitant use of emollients in an appropriate
amount has proved a steroid-sparing effect [116, 117]. Besides their
anti-inflammatory properties, positive cutaneous microbiome effects have
been shown for TCS and TCI.
Promising new topical agents that inhibit key regulators of
pro-inflammatory signals are in clinical development (e.g. topical Janus
Kinase Inhibitors) or have been recently approved (topical selective
phosphodiesterase 4 inihibitor Crisaborole). Further studies will have
to show their potential role in management of AE [112].
In many cases, adequate control of AE can be achieved by topical
treatment options, if applicable even in combination with phototherapy
(e.g. UVB, UVA-1). However, if local therapy remains insufficient, or in
case of severe or persistent disease, systemic treatment is indicated.